Kansas State UniversityJuly 2004Galichia Center on AgingPEAK Project Newsletter Advisory Group Resources Advisory Group ResourcesOne of the most anticipated features of the advisory group meetings is a time period set aside for resource sharing. The following is a list of some of the books and articles recommended by our group at recent meetings. Books Thinking for a Change by John Maxwell Crucial Conversations: Tools for Talking when Stakes are High by Kerry Patterson, Joseph Grenny, Ron McMillan, Al Switzler. The Heart of Change by John P. Kotter Hidden Rules of Class at Work by Ruby K. Payne, PhD & Don L. Krabill Full Steam Ahead! By Ken Blanchard and Jesse Stoner. Jesus CEO by Laura Beth Jones What Leaders Really Do by John P. Kotter The Tipping Point by Malcolm Gladwell A Framework for Understanding Poverty by Ruby Payne Articles Home is Where the Heart is: Designing home-like settings, from IDEAS Consulting Inc. by Margaret P. Calkins, Ph.D. When picking nursing home, consider staffers' satisfaction, by Donald Kausler about Dr. Shu-Chung Chou's studies on nursing home residents' satisfaction and staffs' satisfaction. These studies are contained in the following articles: Measuring resident satisfaction in residential aged care. Choe, S.-C., Boldy, D. P., Lee, A. H. (2002). The Gerontologist 42(2), 188-198. Measuring staff satisfaction and its components in residential aged care. Choe, S.-C., Boldy, D. P., Lee, A. H. (2002). International Journal for Quality in Health Care 14(3), 207-217. Teaching Gerontological Nursing from a New Perspective. Quinn, M. E., Berding, C., Daniels, E., Gerlach, M. J., Harris, K., Nugent, K., Green, C. & Clarke, G. (2004). Journal of Gerontological Nursing 30(1) Culture change in long-term care, Part II by Audrey S. Weiner and Judah L. Ronch found in the Journal of Social Work in Long-Term Care, Volume 2, Numbers 3/4. Crucibles of Leadership by Bennis, Warren G. and Robert J. Thomas. "Crucibles of leadership" Harvard Business Review 80:9 (September 2002). Leading from Within by Palmer, P. (1998). In: Spears, L. C. (Ed) Insights on Leadership: Service, Stewardship, Spirit, & Servant-Leadership. Chap.# 16 (197-208). John Wiley. BEAM Visit Jack Steiner from BEAM (Bringing the Eden Alternative to the Midwest) recently visited our office and met with a few members of our advisory group. He had been reading our work and hearing a lot about the progress of culture change in Kansas and wanted to see firsthand what we are doing here. Jack arrived on June 21 and spent the afternoon visiting Meadowlark Hills and St. Joseph Village here in Manhattan. On Tuesday morning he met with several members of the advisory board in a sharing opportunity. We learned that the BEAM group has expanded from Michigan to include seven states. Jack described the types of training opportunities available through their organization. We all left invigorated by the information that was shared and look forward to future collaborations with BEAM. Feature Article The PEAK-Ed staff recently wrote a feature article for the national publication, Nursing Homes: Long Term Care Management. It was published in the April 2004 issue and highlighted the goals and activities of the PEAK project and the good work being done at Windsor Place in Coffeyville. We experienced an increase in use of our PEAK-Ed web site after its publication and have now had well over 2000 hits. Relevant Quotes Throughout this newsletter you will find side-bars from C. Clyde Jones' 1982 book, Caring for the Aged. Clyde has had a long association with the Center on Aging. Note how little seems to have changed in the twenty-two years since the book was written. This book may be borrowed from our library by calling Pam Evans. "Nursing homes, like most of our institutions, focus on some segment of their clientele and tailor their programs to the needs of that particular subgroup. The reason for this is largely economic. Standardized production has always been more efficient in terms of units of input per units of output. Thus, if we can develop routines for caring for residents which can be repeated endlessly, we can increase the ratio of residents per person employed. Exceptional treatment for individuals disrupts routines, slows production and generally requires either additional employees or fewer services to the remaining residents". (p.3). KDOA Recognition The Journey Toward Culture Change In this newsletter we continue to feature nursing homes that have won the PEAK Award given by the Kansas Department on Aging to recognize nursing homes pursuing "nontraditional" models of care with progressive environments. Featured below are the Pleasant View Home, Inman; Valley View Professional Care Center, Junction City; and Lakeview Village Health Center, Lenexa. Each of these homes received a PEAK Award in 2003 for three domains. Pleasant View Home, Inman "These three things visitors, privacy and personal possessions have been shown repeatedly to be of great importance in the general satisfaction of nursing home residents. (p. 53)." Ninety-five percent of residents at Pleasant View home have private rooms. The other 5% of rooms are reserved for couples or those who want to share a room. This is not a new concept but the way the health care center was originally designed many years ago. The campus is large (220 current residents, 102 in skilled nursing) for such a small town. (Inman population in 2002 was 1222). Person centered care is practiced in neighborhood settings. Pleasant View Home leadership has been working to empower their floor staff to make decisions about resident care. "Letting go is scary," according to their CEO, Kevin Reimer. The staff turnover rate is down 34% this past year in nursing. Teams elected their own leaders. Representatives from each team gather each morning for a 15 minute meeting to review QI issues and learn about new residents. A nurse and another team member each meet with the new residents every day for two weeks to get better acquainted and help the residents get acclimated to their new home. The medical director makes rounds weekly and as needed. Another doctor from Hutchinson comes in regularly as well as a dentist and podiatrist to help keep residents as healthy and active as possible. Five years ago Pleasant View established a secure 20 bed special care section called the Plaza for residents affected by Alzheimer's disease or other dementias. They have since added "Heritage Inn," a twenty-six bed neighborhood for those with early stage memory loss. All staff members in these neighborhoods receive Validation therapy training in addition to the staff training done in-house. When someone new is being hired, neighborhood staff members meet with the potential hire as a part of the interview process to bring in committed staff. Consistent staffing is managed with a permanent every other weekend rotation. The schedule is posted a month in advance and if someone needs to take a day off work they trade with another employee. Pleasant View Home works with the high school and hires students as Patient Care Assistants (PCA). The students who are interested are given scholarships for the CNA course and for restorative training. When high school students pass the certification test they are hired as CNAs at the higher salary. Pleasant View Home maintains an activity based care philosophy to promote resident independence and dignity. Residents garden in raised beds, quilt, and participate in a number of intergenerational programs. A fenced courtyard with cameras has a walking path around the perimeter and comfortable patio furniture where residents can enjoy fresh air. Renovation has been taking place to provide a more home-like environment. Since Pleasant View values the principal of resident autonomy and independence, resident rooms have been decorated in the colors preferred by the individual residents. A lower level has been decorated creatively to hide pipes and cinderblock walls and is carpeted to reduce noise and provide a warmer appearance. Kitchenettes in each neighborhood provide areas for light food preparation, storage and serving the meals that come from the main kitchen. An electric cut off for each stove is located in one of the kitchen cabinets for resident safety. Bread machines provide extra between-meal snacks that residents enjoy. Snacks are also kept in the refrigerator and kitchen cabinets for residents who become hungry or are at risk for weight loss. When the first special care neighborhood opened they believed that when a resident reached the very end stage of the dementia process and did not appear to benefit from the program, the resident would be moved out of the special care unit. They eventually changed that practice. Now residents "age in place" in their special care neighborhood with familiar environment and faces that may be of added comfort in their final days. Valley View Professional Care Center, Junction City Valley View began their journey toward a change in culture after the joint provider/surveyor training on "culture change." Their first course of action was to approach facility owners about some organizational changes at the facility level and about the possibility of some physical changes to the healthcare center. After the owners gave them a green light to proceed, staff, family and resident meetings were held to invite their suggestions on change. They found that even those residents who had been there just a short time had become "institutionalized". Having choices had become foreign to them as they focused on the schedules of the staff rather than their own desires. Staff found it almost impossible to help residents conceptualize the option of "getting up when they wake up" or being able to "choose whatever sounds good to eat" for breakfast. "...Most of the residents are there involuntarily. They are virtually prisoners, unable to come and go as they please. They live in small rooms, often with a roommate chosen for them. They have few personal possessions to tie them to their pasts. They awaken in the morning to a schedule imposed by someone else. They go to meals at hours ordained by the management and eat (or refuse to eat) whatever food the dietary staff chooses. They are bathed (or not bathed) at the convenience of the staff. There is a stultifying sameness to the daily routines of most nursing homes; even those which have planned activities tend to get into boring patterns....(p.35-36)"The administrator and the director of resident services attended an Eden Alternative Associate training and brought the Eden concept back for staff trainings. It was at this time the transition process began in earnest. The central nurses' station was replaced by a garden and fountain park area and charts, forms, etc. were installed in "nurses' dens" on each neighborhood. While this renovation was taking place, numerous in-services were conducted concerning the importance of quality of life for the residents, the meaning of culture change and what it would involve, and the introduction of the neighborhood concept. Although Valley View has prided itself on being "resident centered," they discovered through the seminars and training sessions that with a small change in semantics to resident-directed care, people started to grasp the concept. "A good administrator should want to reduce turnover for economic and morale purposes. He or she can do this through the adoption of innovative personnel policies and procedures. Some of the things (are)...: limit the assignment of aides to specific patients so that they can identify with their patients' needs and progress treat aides as the important individuals they are they are probably the most important person to the patient. (p. 58-59)."Staff members interested in becoming a neighborhood team leader submitted an application, and residents and family members of each neighborhood reviewed the applications and interviewed each applicant. The administrator attended each interview session as a consultant but did not participate in the interview except to answer administrative questions. These interviews revealed what was really important to residents and family members. After the interviews each group discussed the strengths and weaknesses of each candidate they interviewed and came to consensus about their choice for the leader of their neighborhood. Team leaders received training in leadership skills, conflict resolution, time management, budgeting, scheduling, etc. Each has stated that they were not completely prepared to deal with the human resource and staffing issues, but all express feelings of great satisfaction in the changes in the quality of life for their residents. The ultimate goal for neighborhood staff is to be cross-trained for all roles. To date the facility has subsidized the CMA training for 14 CNAs and enrolled 5 CNAs in AD/SSD class. It is not unusual for CNAs, CMAs, LPNs or RNs to cook breakfast or do some room housekeeping in the neighborhood. Valley View residents no longer live for bingo, bible study and birthday parties. Although these activities are still available, their lives are enriched by a more personalized approach. Each neighborhood meets to make plans around what residents want to do. Some activities to date include trips to Milford Lake, a trip to the tulip festival, pot luck dinners, barbecues and a Mardi Gras celebration. Sometimes residents from another neighborhood are invited to join in the fun. Everyone in the neighborhood is actively involved in the care-planning process and at least one team member attends the care plan conference for residents who live in the neighborhood. In the past, CNAs filled out an ADL form for each resident in the assessment period. Now all of the care plan interventions involving direct care staff are documented on the care plan audit sheet and each is expected to read the interventions in place and make appropriate, more realistic changes. The outcome is that now each care plan is a workable instrument! Although Valley View sees itself as "work-in-progress" the beginning stages have brought successes. They have a permanent staff and no longer use agency help, they have developed neighborhoods each with their own mission statement, and they are more cognizant of the fact that they work in the residents' home. These successes have intensified the commitment to continue the process. The ultimate goal is to offer seniors in their community a quality of life where happiness and fun is a primary focus. Lakeview Village Health Center, Lenexa, Lakeview Village formed a task force, with employees representing all departments, to list problems that might arise along the journey of culture change and to develop procedures before a new system was put in place. Their first objectives were to get rid of what they believed were the three most degrading features of traditional nursing homes: the "get-up list", their hot-cart meal procedure, and their battleship nursing station. Even though employees embraced the idea of resident choice and allowing residents to sleep-in, they found their food cart meal system continued to fuel the get-up list. It took awhile to work out the architectural and regulatory (no food preparation) issues but they now have a remodeled galley space with steam tables and refrigeration. This has allowed expanded dining hours with some foods available continuously (as they are at home) and the dreaded get-up list disappeared. Outcomes as a result of the dining changes: Significant weight loss dropped from 15% to 5.9% Unexpected weight loss dropped from 6.1% to 2.5% Remedial recommendations from the consulting dietician dropped from 6.2% to 3.3% Use of supplements dropped from 37.5% to 29.7% ....designers should...develop new concepts which recognize the distinctive nature of nursing homes. Indeed, home should be the key word, rather than nursing. Elderly residents, with a variety of physical and mental impairments, require a barrier-free, supportive environment, but it should not be radically different from their homes. (p. 51-52) With residents and staff coming and going through the extended meal period, residents needing assistance (along with their helper) have become "mainstreamed." This has resulted in challenged residents being visually cued by able residents and their helpers. These residents are also benefiting from the increased socialization. A policy on "Decisional Capacity" was developed and is used to help family members and staff understand that decisional capacity is variable. A resident is often able to decide immediate matters (when to get up, dining choices, etc.) even when the capacity for complex judgments is gone. The policy supports the dignity and abilities (even when limited) of frail residents. Lakeview is now in the process of developing their neighborhood teams. They decided to pilot one neighborhood before they moved everyone to neighborhoods. Because they had chosen to stop using agency staffing they could staff consistently but had a number of new employees. They thought it best to move slowly, form one neighborhood and learn from that pilot neighborhood experience. They removed the big nurses' station and now use small nursing offices for each neighborhood area. Throughout their journey toward a change in culture they have used what they call trust-building education. To continuously reawaken employee's sense of their mission they have small-dose classes (15-20 minutes on the floor) about facets of resident-driven service. About 80% of the health care employees have visited (usually by Lakeview bus) one or more other nursing homes where households or neighborhoods exist. Realizing how important communication is, a small group was formed to ensure ongoing information about changes is readily available to residents, employees and families through newsletters, fliers, signs, and table tents.